Anomalous origin of the right coronary artery from the pulmonary artery with a right coronary artery to left anterior descending artery fistula: A case report

A 75-year-old female patient with a history of arterial hypertension presented with oppressive chest pain radiating to the left upper limb, accompanied by dyspnea on mild exertion. Electrocardiogram showed no significant changes, but positive cardiac biomarkers prompted admission to intermediate care and coronary angiography. Findings included a small-caliber vessel originating from the pulmonary artery trunk and extending toward the right atrioventricular groove, an arteriovenous fistula between the left anterior descending artery and the right coronary artery draining into the pulmonary artery, with significant coronary steal, no stenotic lesions in the epicardial coronaries, and preserved left ventricular systolic function. Coronary CT angiography revealed a high coronary calcium score (5339 Agatston), anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA), diffuse coronary dilatation (Markis I), and diffuse nonobstructive coronary atherosclerotic disease (CAD-RADS N). Cardiac catheterization confirmed preserved systolic function (LVEF 65%), with normal intracardiac pressures and pulmonary resistances but with a Qp/Qs ratio of 1.25. Bilateral pulmonary arteriography showed no significant obstructions. Anatomical and hemodynamic findings were discussed in a multidisciplinary medical meeting with an interventional cardiologist, cardiologist, and cardiovascular surgeon, leading to the decision for surgical intervention.